Every finding on record at Graben Palliative Hospice Care LLC

Upon patient record review, 1 of 5 (Patient #4) did not contain evidence that the Hospice had developed an individualized written Plan of Care for each patient. The Plan of Care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The Plan of Care must include all services necessary for the palliation and management of the terminal illness and related conditions: Patient #4: The POC included an order for Peg Tube/feeding tube. The order did not delineate 'who or how' this tube would be cared for/by. The patient resided in a residential group home.

Upon patient record review, 5 of 5 (Patients #1, 2, 3, 4, and 5) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including the following: A detailed statement of both the scope and frequency of all services necessary to meet the specific patient and family needs: Patient #1: The IDG POC dated 03/05/24 included, "SC 1x month and prn within cert period", without a quantity for such prn visits. Patient #2: The IDG POC included, "SW 1x month and prn for counseling",without a quantity for such prn visits. It also included, "SC 1x month and prn within cert period", without a quantity for such prn visits. Patient #3: The IDG POC included, "SW 1x month and prn", without a quantity for such prn visits. It also included, "SC 1x month and prn within cert period", without a quantity for such prn visits. Patient #4: The IDG POC dated 08/15/23 included, "SC 1x month and prn within cert period", without a quantity for such prn visits. Patient #5: The IDG POC included, "SC 1x month and prn within cert period", without a quantity for such prn visits. It also included, "SW 1x month and prn within cert period", without a quantity for such prn visits.

Upon patient record review, 2 of 5 (Patients #1 and 3) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, specifically equipment and supply needs: Patient #1: During Surveyor-attended home visit 03/19/24, it was noted that the patient had the following DME: 1) Overbed table; and 2) Shower Chair. These DME were not included on the POC. Patient #3: During Surveyor-attended home visit 03/19/24, it was noted that the patient had the following DME: Wheel chair. This DME was not included on the POC.

Upon patient record review, 1 of 5 (Patient #2) did not contain evidence that a revised Plan of Care included information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care: Patient #2: The initial 01/22/24 POC included, "Clean wound to sacrum with Normal Saline, apply Medi-Honey, and cover with 4x4, daily by Hospice Nurse or in-home caregiver." The IDG POC dated 03/05/24 had not been updated with the details of this ongoing, ordered wound care.

Upon patient record review, 1 of 5 (Patient #2) did not contain evidence that Hospice Aide assignments and duties are: Assigned to a specific patient by a Registered Nurse that is a member of the Interdisciplinary Group, to include any pertinent information needed by the Aide while providing patient care/services: Patient #2: The Hospice POC reflected that the patient was a DNR. This pertinent information was not included on the Aide POC.

Upon patient record review, 1 of 5 (Patient #2) did not contain evidence that all entries were legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice: Patient #2: The initial 01/22/24 POC included, "Clean wound to sacrum with Normal Saline, apply Medi-Honey, and cover with 4x4, daily by Hospice Nurse or in-home caregiver." The SN visit dated 02/15/24 documented, "Wound care to sacral area done", without the details of such wound care provided, nor was the wound itself described. The SN visit dated 02/22/24 documented, "Wound care to sacrum done", without the details of such wound care provided, nor was the wound itself described. The SN visit dated 02/29/24 documented, "Wound care done", without the details of such wound care provided, nor was the wound itself described.